Trend and factors associated with healthcare use and costs in type 2 diabetes mellitus: A decade experience of a universal health insurance program
Jur-Shan Cheng PhD1, Wen-Chen Tsai, DrPH2, Chen-Li Lin, MD, MHS3, Likwang Chen, PhD4, Hui-Chu Lang, PhD5, Hui-Min Hsieh, PhD6, Shyi-Jang Shin, MD, PhD7, Ted Chen, PhD8, Chi-Ting Huang, MS4, Chih-Cheng Hsu, MD, DrPH2,4
1Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Taoyuan, Taiwan
2Department of Health Services Administration, China Medical University, No. 91 Hsueh-Shih Road, Taichung, Taiwan
3Taipei City Hospital Fuyou Branch, No. 33, Sec 2, Zhonghua Rd, Taipei, Taiwan
4Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, Taiwan
5Institute of Hospital and Health Care Administration, National Yang-Ming University, No. 155, Sec. 2, Linong St., Taipei, Taiwan
6Department of Public Health, Kaohsiung Medical University, No. 100, Shin-Chuan 1st Road, Kaohsiung, Taiwan
7Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, Kaohsiung, Taiwan
8Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 2300, New Orleans, LA, USA
Corresponding author
Chih-Cheng Hsu, MD, DrPH
Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, Taiwan
Tel: +886-37-246-166 ext. 36336 Fax: +886-37-586-261
Email: cch@nhri.org.tw
Word count: abstract: 249; text: 3,446 Number of text pages：29
Number of references：42 Number of tables and figures: 5
Disclosure of funding: This study was supported by a grant from the Taiwanese Ministry of Science and Technology (NSC 99-2314-B-400 -002 -MY2).
Running title: Use and costs of healthcare for type 2 diabetes
Complete author information Jur-Shan Cheng, PhD
Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Taoyuan, Taiwan
Tel: +886-3-211-8800 ext. 3810 Fax: +886-3-211-8453
Email: jscheng@mail.cgu.edu.tw Wen-Chen Tsai, DrPH
Department of Health Services Administration, China Medical University, No. 91 Hsueh-Shih Road, Taichung, Taiwan
Tel: +886-4-2205-3366 ext. 6302 Fax: +886-4-2202-8895
Email: wtsai@mail.cmu.edu.tw Chen-Li Lin, MD, MHS
Taipei City Hospital Fuyou Branch, No. 33, Sec 2, Zhonghua Rd, Taipei, Taiwan Tel: +886-2-2391-6470 ext. 1221
Fax: +886-2-2351-3153 Email: DAE34@tpech.gov.tw Likwang Chen, PhD
Division of Preventive Medicine and Health Services Research, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, Taiwan
Tel: +886-37-246-166 ext. 36311 Fax: +886-37-586-261
Email: likwang@nhri.org.tw Hui-Chu Lang, PhD
Institute of Hospital and Health Care Administration, National Yang-Ming University, No. 155, Sec. 2, Linong St., Taipei, Taiwan
Tel: +886-2-2826-7015 Fax: +886-2-2823-7298 Email: hclang@ym.edu.tw Hui-Min Hsieh, PhD
Department of Public Health, Kaohsiung Medical University, No. 100, Shin-Chuan 1st Road, Kaohsiung, Taiwan
Tel: +886-7-312-1101 ext. 2141 then 48 Fax: +886-7-311-0811
Email: hsiehhm@kmu.edu.tw Shyi-Jang Shin, MD, PhD
Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, Kaohsiung, Taiwan
Tel: +886-7-312-1101 ext. 7375, 7377 Fax: +886-7-312-2810
Email: sjshin@kmu.edu.tw Ted Chen, PhD
Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 2300, New Orleans, LA, USA
Tel: 504-988-5378 Fax: 504-988-3540 Email: tchen@tulane.edu Chi-Ting Huang, MS
Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, Taiwan
Tel: +886-37-246-166 ext. 36386 Fax: +886-37-586-261
Email: gorilla0409@nhri.org.tw
Chih-Cheng Hsu, MD, DrPH (corresponding author)
Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, Taiwan
Tel: +886-37-246-166 ext. 36336 Fax: +886-37-586-261
Trend and factors associated with healthcare use and costs in type 2 diabetes mellitus: A decade experience of a universal health insurance program
Abstract
Background: Little is known about how a universal national health insurance (NHI) program with cost-containment strategies affect costs and quality of diabetes care.
Objectives: To examine the trends of healthcare use and costs for patients with type 2 diabetes mellitus (T2DM) in Taiwan over the last decade, and to identify factors associated with high healthcare cost and poor diabetes care.
Research Design: We delineated the pattern of healthcare use and costs for T2DM in 2000-2010. Generalized linear and logistic regression models were used to identify factors associated with medical costs and diabetes care.
Subjects: Representative adult T2DM patients and age- and gender-matched non-diabetes individuals were selected from the 2000, 2005, and 2010 NHI Research Databases.
Measures: Healthcare use included physician visits, hospital admissions, and antidiabetic drug prescriptions. Indicators of diabetes management included completeness of
recommended diabetes tests and medication adherence, assessed using medication possession ratio.
Results: The total healthcare cost per diabetes patient was approximately 2.8-fold higher than that for non-diabetes individual. The growth of healthcare cost per diabetes patient was significantly contained by about 3,694 NTD (3.6%) between 2005 and 2010, but diabetes care improved over the decade. Diabetes duration, income, place of residence, continuity of
care, and enrollment to a pay-for-performance program were associated with healthcare costs and diabetes management. Some public health measures implemented to support diabetes care were also discussed.
Conclusions: Healthcare costs could be controlled without sacrificing the quality of diabetes care by implementing pay-for-performance programs and effective health policies favorable for diabetes care.
Introduction
Type 2 diabetes has caused tremendous health and economic burdens worldwide (1-5). Patients with diabetes incur high healthcare costs, especially when they have poor diabetes control and develop macrovascular and microvascular complications. The projected
escalation in the number of diabetes patients in both developing and developed countries for the next 20 years (6) is expected to further encumber the global economy.
To prevent diabetes complications, clinical guidelines suggest optimizing patients’ metabolic profiles, including blood glucose and cholesterol control (7,8). However, there is always a gap between actual diabetes services received and ideal care models recommended (9,10). Additionally, between 7% and 64% of patients were found to be non-adherent to their medication regimen (11–14). Therefore, diabetes is often poorly controlled and becoming a common cause of devastating health consequences, such as dialysis, amputation, and blindness (15,16). How to renovate a healthcare system to enhance the accountability of health providers, encourage treatment adherence among patients, and at the same time control medical costs is an imperative task for medical societies, especially in the era of escalating healthcare costs.
Taiwan has implemented its comprehensive and universal National Health Insurance (NHI) program since 1995 (17). Owing to the aging of Taiwan’s population and the
over the past 15 years, from 143 billion New Taiwan dollars (NTD) in 1995 to 297 billion NTD in 2000, 420 billion NTD in 2005, and 500 billion NTD in 2010 (18). In response to the risk of a debilitating financial deficit, the NHI Administration (NHIA) has adopted many countermeasures to manage the expansion of the program’s spending. The diagnosis-related groups (DRG), a sliding fee schedule for outpatient visits, reductions in drug prices, and a global budget (GB) payment system are some of the many strategies by which the NHIA has used to reduce runaway growth in costs (19,20). Consequently, the growth rate of NHI expenditures decreased from 107% between 1995 and 2000, to 41% between 2000 and 2005, and further down to 19% between 2005 and 2010 (18).
It is important to know how these unprecedented cost-containment measures affected healthcare use and costs of diabetes patients, and whether quality of diabetes care were compromised due to these measures over the last decade. In addition, information on what and how patient characteristics, disease severity, healthcare seeking pattern, and policy intervention were associated with diabetes care can be of help to design a more efficient program (3,21-29). This study, therefore, aimed to investigate the trends and factors
associated with costs and diabetes care in Taiwan in an era of pursuing both quality assurance and cost containment.
Data and study sample
The Longitudinal Health Insurance Database (LHID) for the years 2000 (LHID2000), 2005 (LHID2005), and 2010 (LHID2010) were obtained from the NHI Research Database. Each LHID was derived by randomly selecting 1,000,000 enrollees from the Registry for
Beneficiaries of the respective year (22). There were no significant differences in the age and sex distributions between the selected samples and the NHI enrollees for the respective years. The LHIDs provided detailed records of what was reimbursed under NHI’s comprehensive coverage.
In each observed year, adult type 2 diabetes patients (age ≥ 20) were identified based on the following inclusion criteria: (1) hospital admission for diabetes-related illness (ICD-9-CM: 250.xx) or treatment with antidiabetic drugs during the hospitalization; (2) at least one antidiabetic drug prescription and one outpatient visit for diabetes-related illness within 1 year; or (3) at least four outpatient visits for diabetes-related illness within 1 year. The comparison group consisted of non-diabetes individuals, one-to-one age- and gender-matched to the diabetes patients.
To examine factors associated with healthcare costs and diabetes care, subjects in the samples of 2005 and 2010 were further divided into four groups based on their diabetes durations: 1–2 years, 3–4 years, 5–6 years, and > 6 years. In each group, 1000 subjects were randomly selected so that individuals from different years and with different diabetes
durations were equally represented in the sample set. In total, 8000 subjects were therefore selected. Patients in the sample of 2000 were not included in this association study because the pay-for-performance (P4P) diabetes care program had not yet been implemented in 2000. Measurement
The utilization and costs of healthcare services, including physician visits, hospital
admissions, and antidiabetic drug prescriptions were calculated from the NHI reimbursement claims. To illustrate diabetes-specific healthcare costs, the total healthcare costs including inpatient and outpatient care were also decomposed and classified into three categories based on principal diagnosis of the NHI claims: (1) Diabetes-related costs (ICD-9-CM: 250.xx); (2) Vascular comorbidity-related costs: the costs of healthcare services due to stroke, ischemic heart disease, congestive heart failure, peripheral vascular disease, nephropathy, neuropathy, and diabetes-related eye diseases (15,31,32); and (3) Other costs: costs not included in (1) or (2). All costs were adjusted to 2010 NT dollars using the Consumer Price Index. The
exchange rate of US dollars to NT dollars was approximately 1:30.
The indicators of diabetes care included (1) annual tests for fasting glucose, glycated hemoglobin (HbA1c), low-density lipoprotein (LDL) cholesterol, triglycerides (TG), serum creatinine, urine dipstick analysis, urine microalbumin analysis, and retinopathy checkup in outpatient visits; and (2) good medication adherence, defined as a medication possession ratio (MPR) ≥ 80% (12,13,23). MPR was measured by dividing the sum of prescription days of
antidiabetic drugs from outpatient visits by the total number of non-institutionalized days during the year.
The care-seeking pattern was defined by the frequency and continuity of diabetes-related physician visits. Those with fewer than three visits in one year were considered as the irregular diabetes care group. The continuity of care index (COCI) (34) was measured for patients with regular diabetes care. Higher COCI scores indicated better continuity of care. Statistical analysis
A difference-in-difference method was employed to test differences in the trends of the use and costs of medical services between diabetes and non-diabetes individuals in 2000, 2005, and 2010, treating the data in 2005 as references. Generalized linear models (GLMs) with a negative binomial distribution were adopted for use of health services. GLMs with a log-link and gamma distribution were used for costs of health services. A two-part model was used to analyze the use and cost of inpatient services because most subjects were not
hospitalized in the observational period (35). The first part was a logistic regression model to estimate the probability of receiving inpatient services. The second part was a GLM with a log-link and gamma distribution to estimate inpatient costs conditional on having received such services. In these models, there was a dichotomous variable denoting patients with diabetes, two dichotomous variables denoting the index year (2000 or 2010), and interaction terms of diabetes and index years as independent variables. Trend analyses were used to see
the long-term trend for the P4P program enrollment, care-seeking pattern, and receipt of diabetes-related tests. A logistic model was adopted to look at the change in 2000, 2005, and 2010 for receipt of antidiabetic drug therapy.
In investigating the associations of factors with healthcare costs for diabetes patients, the same types of models aforementioned were utilized. Factors associated with good
medication adherence (MPR ≥ 80%) and completeness of annual HbA1c testing were
assessed using logistic regression models. All models consisted of the following independent variables: (1) patient characteristics: age (20-39, 40-49, 50-59, 60-69, ≥70), gender (male, female), insurable income level (poor, low income, middle income, or high income) (25), NHI registration location (city, township, or rural area); (2) time: year (2005 or 2010); (3) disease severity: diabetes duration (1–2 years, 3–4 years, 5–6 years, or > 6 years), vascular comorbidities (stroke, ischemic heart disease, congestive heart failure, peripheral vascular disease, nephropathy, neuropathy, and retinopathy); (4) policy intervention: the P4P program enrollment; and (5) care-seeking pattern: no regular diabetes-related physician visits [< 3 visits/year], low continuity of care [COCI < 0.77], high continuity of care [COCI ≥ 0.77]. The median of COCI (0.77) was chosen as a cut-off point. SAS software version 9.1 (SAS
Institute, Cary, NC) was used to perform the analyses.
This study was granted ethical approval by the Institutional Review Board of the National Health Research Institutes of Taiwan.
Results
Trends in healthcare use and costs and diabetes care
The percentage of adult NHI enrollees diagnosed with type 2 diabetes increased from 4.46% (28,482 of 638,941) in 2000 to 5.92% (43,427 of 733,040) in 2005 and 7.57% (57,883 of 764,173) in 2010. The percentage of total healthcare spending dedicated to diabetes patients increased from 19.03% in 2000 to 25.37% in 2005 and 28.86% in 2010 (data not shown).
Figure 1 demonstrates that the total healthcare cost per diabetes patient was
approximately 2.8-times the cost spent by the age- and gender-matched individuals without diabetes (2.78-fold in 2000, 2.95-fold in 2005, and 2.72-fold in 2010), and about 40% of the cost was due to diabetes and related vascular comorbidities. In P4P enrollees and non-P4P enrollees, total healthcare cost per patient was about 2.1-times and 3.0-times the cost per matched individuals, and diabetes and related vascular comorbidities accounted for approximately 50% and 37% of the cost, respectively.
Diabetes and non-diabetes individuals differed in their NHI registration location, income level and vascular comorbidities (Table 1). Additionally, diabetes patients consumed more health services and incurred higher healthcare costs. The average number of annul physician visits among diabetes patients decreased from 30.6 in 2005 to 28.2 in 2010 and their hospital admissions decreased from 0.58 in 2005 to 0.55 in 2010. As a result, the different-in-difference estimates were a net reduction of 2.2 visits and 0.03 admissions from
2005 to 2010, respectively.
From 2000 to 2005, the average total healthcare cost, outpatient costs and inpatient costs increased among both diabetes and non-diabetes individuals. However, from 2005 to 2010, despite the still rise in the average outpatient cost for both groups, the distinctive changes of the average inpatient and total cost between the diabetes and non-diabetes groups became obvious: the average inpatient cost decreased by 5150 NTD for diabetes but only 141 NTD for non-diabetes individuals, the total healthcare cost decreased by 3694 NTD for diabetes but increased by 1628 NTD for the non-diabetes counterparts. As a result, the average total healthcare cost between diabetes and non-diabetes groups was a net increase of 15,752 NTD from 2000 to 2005, but a net decrease of 5,322 NTD from 2005 to 2010.
In both 2005 and 2010 approximately 19% of patients with diabetes were enrolled in the P4P program. The proportion of patients without regular diabetes-related physician visits increased slightly, from 11.0% in 2000 to 11.9% in 2010, while the mean COCI score of those with regular visits increased from 0.62 in 2000 to 0.72 in 2010.
The number of diabetes-related outpatient visits followed the same trend as the number of overall outpatient visits in diabetes patients. As the percentage of patients
receiving antidiabetic drug therapy increased from 2000 to 2005 but decreased from 2005 to 2010, cost of antidiabetic drugs increased by 2,328 NTD from 2000 to 2005 but decreased by 382 NTD from 2005 to 2010.
The percentage of completeness of annual diabetes-related tests — including HbA1c, LDL, TG, serum creatinine measurements, urine dipstick analysis, urine microalbumin analysis, and retinopathy checkup — significantly increased over time (Figure 2). A total of 37.9% of patients with diabetes completed an annual HbA1c test in 2000, while 79.9% completed the test in 2010. In 2000, 46.8% of treated diabetes patients were adherent to antidiabetic drug therapy (MPR ≥ 0.8); this percentage increased to 62.4% and 67.1% in 2005 and 2010, respectively. The percentage of completeness of annual diabetes-related tests and medication adherence were higher in P4P enrollees than in non-P4P enrollees. However, there was improvement in completeness of tests and medication adherence from 2005 to 2010 in both groups.
Factors associated with healthcare use and costs and diabetes care
Patients with different diabetes durations differed in age, gender, vascular
comorbidities, care-seeking pattern, and percentages of being adherent to antidiabetic drug therapy and completing HbA1c tests (Table 2). Additionally, there was discrepancy in use and cost of outpatient care and inpatient care, and antidiabetic drug costs.
In the multivariable analyses of healthcare use and costs, patients with diabetes durations > 6 years (OR=1.19), who lived in rural areas (OR=1.31), who were poor
(OR=2.31), and who had no regular diabetes-related visits (OR=1.52) were more likely to be admitted to hospital (Table 3). Individuals with diabetes duration > 6 years, who were poor,
and who did not seek regular diabetes-related visits incurred higher total healthcare costs. The P4P program enrollment and better continuity of care were associated with a lower risk of hospital admission (OR=0.71 and OR=0.45, respectively), and had lower total medical costs (-7,621 NTD and -14,008 NTD, respectively).
The results of the analyses of diabetes care demonstrated that individuals who had diabetes for 1–2 years, those located in rural areas and who had no regular diabetes-related visits were less likely to be adherent to antidiabetic drug therapy (OR=0.67, OR=0.82 and OR=0.003, respectively). Diabetes patients in 2010 (OR=1.30), who participated in the P4P program (OR=1.45), and who had better continuity of care (OR=1.53) were more likely to have good medication adherence. Patients with diabetes in 2010 and enrollment in the P4P program were further associated with completeness of HbA1c test (OR=3.33 and OR=8.44, respectively). Individuals lived in rural area (OR=0.70), poor patients (OR=0.48), and who did not seek regular diabetes visits (OR=0.14) were less likely to complete HbA1c tests.
Discussion
This study investigated the trends of costs and diabetes care in Taiwan from 2000 to 2010, and identified factors associated with healthcare costs and diabetes care. Our findings indicated that the prevalence of type 2 diabetes in Taiwan increased over the decade, as did the percentage of total healthcare expenditures spent by all diabetes patients; however, the
growth of the healthcare cost per diabetes patient was contained between 2005 and 2010. Moreover, quality of diabetes management and continuity of care have improved for the past 10 years. Additionally, diabetes duration, NHI registration location, income, the P4P program enrollment, and care-seeking pattern were found to be correlated with healthcare costs and diabetes management.
One study analyzing the 1997–1998 NHI claims data in Taiwan found that 2.6% of the total population had diabetes, who accounted for 11.5% of the total healthcare
expenditure (4). These findings, together with ours, further confirmed the trends of increasing prevalence and total healthcare spending for diabetes patients in Taiwan. In this previous study, the total healthcare cost per diabetes patient was 4.3-fold higher than that for non-diabetes individual, which was much higher than our estimate, 2.8-fold. This discrepancy might be due to the mismatched distribution of age and gender between diabetes and non-diabetes populations, which were not controlled in the previous study.
To respond to the financial challenges in sustaining the NHI program, the NHIA has adopted a series of cost-containment measures and contained the growth rate of NHI
expenditures for the past decade (18). In regard to the cost of diabetes patients, the pattern is similar. We found the diabetes healthcare cost per patient in 2005 was significantly higher than that in 2000; however, such an increase was not shown between 2005 and 2010 (the crude monetary values in Table 1 demonstrated a decrease, and the adjusted estimate in Table
3 indicated no difference). In the meantime, our results showed improvement both in completing recommended diabetes tests, consistent with previous study (31), and in adherence to antidiabetic drug therapy, regardless of P4P program enrollment.
It is speculated that the quality of diabetes care is not jeopardized by the continuous cost down because of the collective public health achievements. For example, the Health Promotion Administration (HPA) has launched national projects such as nationwide diabetes awareness campaigns, organized patient self-help groups, and created a licensing system to qualify diabetes care providers over the past decade (36), all of which were designed aiming at better diabetes care. The diabetes shared care network, established by the Ministry of Health and Welfare in 1996 and aimed to integrate healthcare resources and personnel for providing optimal diabetes care in the community, was expanded in the decade. The number of diabetes health promotion organizations in the network has increased from 139 in 2005 to 167 in 2010 (37). All the measures, together with the finding that most diabetes self-care behaviors have been significantly improved (38), indicate the health system in Taiwan has become increasingly supportive of diabetes care over the years. The lesson learned from Taiwan demonstrated that the financial constrains may not necessarily damage the quality of management for chronic diseases such as diabetes as long as proper public health
interventions are implemented.
associated with improved process measures of diabetes care both in our study and previous research (28,29), as this program is designed to give clinicians incentives to incorporate multidisciplinary teams to provide diabetes patients with health education and dietary counseling, conduct necessary laboratory evaluations, and reinforce case management for their patients. However, a P4P program may induce discrimination against sicker patients (39), and its impact on quality of care and health outcomes has also not been fully confirmed (40). In our study, P4P enrollees, compared to non-P4P enrollees, incurred lower costs and had better diabetes care. After adjusting for diabetes severity-related factors such as diabetes duration and vascular comorbidities, the benefits remained, implying that patients of the same disease severity could benefit from the P4P program. Therefore, we believe that a properly designed P4P diabetes care program can play a vital role in maintaining quality of diabetes care in the cost-containment era.
Continuity of care is generally associated with diabetes-related hospitalization, emergency room visits, pharmaceutical expenses, total healthcare costs, and better adherence to antidiabetic drug therapy (26,27). In this study, we further illustrated that better continuity of care in diabetes patients could reduce all-cause hospital admissions, outpatient costs, and total healthcare expenditure. The improvement in continuity of care is a proxy indicator of a better patient–physician relationship that could reduce healthcare costs by the avoidance of “doctor shopping” (41). Those without regular diabetes-related physician visits (< 3 visits per
year) were less likely to complete HbA1c tests, less adherent to their treatment regimens, and tended to consume more inpatient services. These findings demonstrated the importance of targeting this group of patients and actively improving their care-seeking behavior.
Longer diabetes duration is found to be associated with increased outpatient cost and total medical costs as in previous research (3,21). Our findings indicate that patients with shorter diabetes durations (< 3 years) were less likely to stay with antidiabetic drug therapy, and had the highest proportion of having no regular diabetes-related outpatient visits,
indicating special attentions should be paid to new diabetes patients to improve their disease awareness.
Patient characteristics including place of residence and socioeconomic status were found to be associated with healthcare costs and diabetes management, consistent with previous research (3,23-25). Our findings indicate that improving accessibility in rural areas and increasing accountability of health providers for the poor are essential to improving diabetes care.
Although Taiwan has improved its diabetes management, we have identified some areas for further improvement. For example, more than 50% of diabetes patients still had not completed annual checkups for proteinurea and retinopathy in 2010. In addition, only about 20% of diabetes patients were enrolled in the P4P diabetes care program in 2010, indicating more outreach efforts are needed for the patient enrollment.
There were several limitations to this study. First, there were no biochemical data to confirm the diagnosis of diabetes or its severity. Therefore, this study adopted an algorithm used in other studies to identify patients with diabetes (25,42) and used the existence of diabetes-related comorbidities and diabetes duration as proxies for diabetes severity. Second, the actual consumption of prescribed antidiabetic drugs was not available; therefore, a commonly used indicator, the MPR, was adopted. As more than 90% of hospitals and clinics are contracted by the NHIA, NHI claims data were a proper source to estimate the possession of medications by patients. Third, this was not a prospective cohort study; therefore no causality relationships can be inferred.
In conclusion, this study demonstrated that although total healthcare expenditures rose due to increases in the number of diabetes patients, the growth of medical costs per patient could be contained and diabetes care could also be improved through proper implementation of a P4P diabetes care program and of dedicated diabetes-related public health campaigns. Although the universal health insurance program improved access to medical care, the poor, individuals living in rural areas, and those with short diabetes durations need to be targeted to improve their diabetes management.
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Figure legend
Figure 1. Trends of the total healthcare costs per person in (A) type 2 diabetes patients and age- and sex-matched non-diabetes individuals from 2000 to 2010; (B) type 2 diabetes patients enrolled in P4P program and age- and sex-matched non-diabetes individuals from 2005 to 2010; and (C) type 2 diabetes patients not enrolled in P4P program and age- and sex-matched non-diabetes individuals from 2000 to 2010. (
)
Diabetes-related costs, incurred from the healthcare services with diagnosis of ICD-9-CM 250.xx; ( ) Vascular comorbidity-related costs, the healthcare costs due to stroke, ischemic heart disease, congestive heart failure, peripheral vascular disease, nephropathy, neuropathy, and diabetes-related eye diseases; ( ) Other costs, the healthcare services costs other than the diabetes-related and vascular comorbidity-related costs.Figure 2. Percentage of receiving recommended tests or having medication possession ratio (MPR) >80% in (A) diabetes patients from 2000 to 2010; (B) diabetes patients enrolled in P4P program from 2005 to 2010; and (C) diabetes patients not enrolled in P4P program from 2005 to 2010 (P value for trend test).
